Fifty Shades of Sexual Offending – Part III: Exhibitionistic Disorder
A newspaper headline in 2017 reads “Recalcitrant Flasher Gets 3 Months Jail”. A married man, and a father of two young daughters, why did he keep exposing his private parts in public and attracting charges of insulting a person’s modesty, bringing shame and embarrassment to his family? He has been in and out of prison in the past 16 years. One may ask, “When will he learn his lesson?” Other would comment “he is a menace to the public; there is clearly something wrong with him; it’s perverted behaviour”, what else has been done to understand people who repeatedly expose themselves and get into trouble with the law? Is our prison or mental health facilities equipped with offence-specific treatment and rehabilitation regimen to help this group? I doubt. It has been 16 years. Exhibitionistic acts are not just “perverted behaviour”, it is a mental disorder not many people bother to know and understand. Isn’t it obvious that something should have been done to help his plight long ago?
Part III of “Fifty Shades of Sexual Offending” will focus on Exhibitionistic Disorder.
What is Exhibitionistic Disorder?
Exhibitionistic Disorder is a Paraphilic Disorder in which an individual derives sexual pleasure and gratification from exposing his or her genitals to non-consenting persons. There is a persistent and intense atypical sexual arousal pattern that is accompanied by clinically significant distress (eg, guilt, shame, intense sexual frustration, loneliness) and impairment in functioning (eg, social, occupational, and interpersonal). The act of exposing is undertaken for the purpose of achieving sexual excitement, sometimes followed by masturbation and orgasm. The act in itself is not deviant or illegal, but the involvement of a non-consenting victim, which transgresses interpersonal boundary, makes it so.
Despite being one of the most common of sex offences, the true prevalence and incidence of exhibitionism are unknown. Exhibitionistic acts are commonly under-reported by victims, although they do occur frequently. It is estimated that a third to half of all sex crimes reported to the police are related to exhibitionism.
Most people tend to think that men are disproportionately more likely to expose their genitals than women, and that Exhibitionistic Disorder/ Exhibitionism is primarily a male disorder. The fact is both genders are equally exhibitionistic in their own ways (eg, mini-skirts, bikinis, porn stars and nude beaches). Some women enjoy the thrill of showing their naked or minimally clothed bodies to a complete stranger to provoke reactions, which also encourage acts of voyeurism or “upskirt”. While a naked woman is viewed as vulnerable or promiscuous, a naked man is viewed as dangerous and threatening (or siao lah). The reactions they induce from their viewers could be drastically different — admiration or lust vs fear or disgust, so are the outcomes should someone decide to report their exposing acts to the police.
In non-clinical or general populations, it is estimated that 2% to 4% of the male population engaged in exhibitionistic acts; there are no reported figures for the female population (DSM-5, APA, 2013). Mostly an early-onset disorder, adolescence is the period where exhibitionists (also known as “flashers”) often report first becoming aware of their sexual interest in exposing their genitals to unsuspecting persons, although they may only come into contact with the criminal justice system in their mid-20s or later.
Children, adolescents and women are frequent targets of exhibitionists. Research studies that focus on victims of sex offending also unearthed some information about exhibitionism. Exhibitionists tend to have multiple victims across time, which may inflate the actual numbers of exhibitionists.
Exhibitionists are noted not to have a set deviant sexual arousal patterns, ie, they are not primarily attracted to exposing themselves; nor do they have a preference of exposing themselves as shown in penile tumescence studies.
The model of multiple pathways of sex offending proposed that family environment, learning history, biological factors and cultural factors can increase an individual’s vulnerability, which can lead to common clusters of problems such as deviant sexual scripts and relationship schemas, intimacy deficits, inappropriate emotions, and cognitive distortion (Ward and Siegert, 2002).
Assessment and Diagnosis
An ‘Assessment of Exhibitionistic Disorder’ is done by taking a detailed history of one’s psychosexual development which covers compulsive masturbation, compulsive use of pornography, illegal or atypical sexual behaviour and fantasy, urges and propensity to act out sexually, hypersexuality, sexual impulsivity, psychiatric comorbidities, interpersonal deficits, psychosocial impairment and subjective distress.
Forensic history of indecent exposure, molest, insult or outrage of modesty should be explored in detail. The most common areas of assessment include (a) offence pattern (the locations chosen for the exposure), (b) victim preference, (c) frequency of behaviour, (d) compulsivity, (e) duration of behaviour, (f) motivation (the thoughts and feelings about the exposure) and amenability for treatment, and (g) variety of offending behaviour.
Neuropsychiatric conditions like history of head trauma, medications, substance use and neurological conditions relating to disinhibition and sexually aggressive behaviour should be ruled out. Psychometric testing looking at personality attributes and psychopathology, polygraphy, as well as psychophysiological measures like penile plethysmography are employed occasionally.
Diagnostic Criteria of Exhibitionistic Disorder (302.4; DSM-5)
- Over a period of at least six months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviours.
- The individual has acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specifiers of Exhibitionistic Disorders Include:
- Sexually aroused by exposing genitals to pre-pubertal children.
- Sexually aroused by exposing genitals to physically mature individuals.
- Sexually aroused by exposing genitals to pre-pubertal children and to physically mature individuals.
A diagnosis of Exhibitionistic Disorder can be made regardless of whether an individual discloses, admits or denies his or her behaviour if there is recurrent exhibitionistic behaviour which fulfils the criteria listed above. Multiple arrests and convictions for exposing acts over a considerable period would support the diagnosis.
Exhibitionistic Disorder, whilst a Paraphilic Disorder, also shares features of Sexual Compulsivity (an Impulse Control Disorder) and is considered to be a highly compulsive and repetitive behaviour.
Individuals diagnosed with Exhibitionistic Disorder often reported preoccupation with sexual fantasies of exposing their genitals to unsuspecting strangers. Their exposures are usually planned, and are rarely an impulsive act although they may believe so at that time. Exhibitionists indeed may spend a considerable amount of time cruising and looking for their victims, which further isolate themselves socially, leading to withdrawal from prosocial activities like spending time with family, co-workers and friends, or pursuing hobbies.
To some exhibitionists, seeing the fear and disgusted reactions from the victims further excites them. Their exhibitionistic activities may increase when there are life stressors, and acting out becomes a maladaptive coping strategy. Some exhibitionists experience low mood, guilt and shame with their out-of-control behaviour, which may cloud their judgment and reduce their impulse control further (eg, oblivious to CCTVs in the surroundings), which often puts them in potentially higher risk situations of being apprehended.
Although exhibitionistic behaviours tend to occur frequently and the likelihood of arrest is high, over the years, I have only assessed a handful of exhibitionists who were charged in Court and referred by lawyers. The small number could be due to the fact that some of these first-time arrest offenders were given a warning and let off, or they were charged but did not engage any lawyer which is the usual route of being referred for a medico-legal assessment that looks into the causes and circumstances of their offence commission. There is also the possibility that only the more severe cases act out frequently enough and get arrested. These more severe cases may also have a more complicated presentation with multiple issues.
What we know about this group of sex offenders is in fact very limited and may not be representative enough. Very often, societal stigma and stereotypes categorise flashers as “perverted”, giving them little empathy or understanding because their acts of exposure traumatize the victims. The fact that a flasher may expose himself near his residence or in the neighbourhood may lead to considerable stress and embarrassment for his family, so is the extensive and sensational media coverage of their “perversion”. Needless to say, Exhibitionistic Disorder can have a major impact on the individual and his family.
Compared to child molestation or rape, exhibitionism receives little research and attention despite being one of the more frequently occurring sex offences and affecting a large number of victims. From the findings of sex offender treatment programs overseas, it is found that common co-existing disorders in exhibitionists include mood disorders, anxiety disorders, substance use disorders, attention-deficit/hyperactivity disorder, hypersexuality, other paraphilic disorders and anti-social personality disorder.
Multiple paraphilias (voyeurism in particular) appear to be the rule rather than the exception in individuals who have exposed themselves to unsuspecting individuals. An individual may be convicted for exposing himself and labelled an exhibitionist. However, exposing may not be his sole, or even primary, paraphilia. Paedophilia is of particular significance and should be evaluated if the exhibitionists solely expose to children (the victims); as the exposure could be seen as part of “grooming”, which may progress to more serious form of “hands-on” sexual offending (ie sexual activities with children). Offenders with anti-social personality traits are more likely to offend in non-sexual crimes.
Paraphilia-related disorders like compulsive masturbation, protracted heterosexual/homosexual promiscuity, dependence on pornography and cybersex, and severe sexual desire incompatibility are common among exhibitionists, and may play a role in their offending.
Exhibitionistic Disorder and Offending
Is exhibitionism merely a nuisance behaviour that causes little harm to the victims as rationalised by those who engaged in it? Acts of indecent exposure are considered misdemeanours or law-breaking sexual behaviours in most jurisdictions. In the US, indecent exposure can be charged as a misdemeanour or felony depending on the circumstances of offence commission and one’s criminal record, and necessitates a lifetime sex offender registration.
In Singapore, indecent exposure is governed by a number of sections of the Singapore Statutes. Under section 27A of the Miscellaneous Offences (Public Order and Nuisance) Act, “appearing nude in public or private place” is illegal; private place would include your own residence if you happen to be naked and are visible to non-consenting individuals. Similarly, under section 268 of the Penal Code, a person is guilty of a public nuisance if his or her act causes annoyance to the public.
While SPF statistics noted an uptrend in outrage of modesty cases from 2016 to 2017, there are no figures about insult of modesty cases. Lim, Tan, Sung, Chan and Straughan (2000) in a review of offenders remanded at the Institute of Mental Health (IMH), noted that 23.4% committed “acts of indecency”. There was no elaboration as to what these acts were, but it is likely to be referring to acts of indecent exposure.
Under section 509 of the Penal Code, an individual could be charged for words or gestures that are intended to insult the modesty of a woman; so is an obscene act (eg, exposing one’s genitals) performed in public place to the annoyance of others (section 294). Depending on how the offence took place (eg any criminal trespass) and whether the offender had used criminal force (eg, touching the victims with one’s genitals) to outrage the modesty of a person (section 354), more charges could be laid.
Exhibitionists are often non-violent. Exhibitionistic acts, ie “hands-off offences”, may appear harmless. However, they do have a traumatising effect on the victims. There is also a possibility that an offender may progress or escalate to physical offences. Amongst sex offenders who committed physical offences, two-thirds of them have admitted to having committed hands-off offences. Prior criminal history (sexual and non-sexual) was found to be predictive of recidivistic exposure offences.
Treatment of Exhibitionistic Disorder
There is a saying about exhibitionists being more self-disclosing than other sex offenders because “they are people who expose themselves”. The exhibitionists I have assessed were co-operative in disclosing their exposing history. Without treatment, exhibitionists tend to repeat their behaviour due to its highly compulsive nature.
We have read news about recalcitrant flashers getting sentenced to jail repeatedly, as if they never change. However, they never change not because they are bad people, but simply because there is a lack of support and treatment that addresses sexual paraphilias and their respective offending.
Exhibitionism is a highly embarrassing and therefore isolating behaviour. Sufferers have few opportunities to discuss their behaviour with others. In fact, some exhibitionists display denial and minimisation when it comes to the seriousness of their offences, while others are unaware of their distorted thinking and deficit in social skills.
Exhibitionistic acts are often used as a maladaptive coping strategy to counter life stresses, boredom and negative emotions. Exposures often involve a build-up of tension that is relieved through acting out. It is believed that endorphins are produced in the process, which may function as a mood regulator and reinforce the behaviour, which then becomes a vicious cycle.
Cognitive behavioural approaches are found to be effective in reducing exhibitionistic behaviour. The primary goals of cognitive behavioural programmes focus on offence responsibility, cognitive restructuring, relationship skills, social skills, victim impact/empathy, relapse prevention, arousal control, and family support.
In terms of pharmacological treatment, serotonin is a neurotransmitter that has an inhibitory effect on male ejaculatory functioning. Medication like selective serotonin reuptake inhibitors (SSRIs) (eg fluoxetine, fluvoxamine, sertraline) can be used to control unwanted sexual arousal, reduce hypersexual symptoms (eg compulsive masturbation) and deviant sexual fantasies, urges, and contacts, and in mitigating sexual impulsivity. Comorbidities like depression, anxiety and other sexual paraphilias should be treated concurrently.
Unfortunately, psychopharmacological interventions remain under-researched and under-utilised in mental facilities in Singapore. I have heard stories of patients being medicated with unsolicited sleeping pills at a state mental facility, so that they would sleep instead of going out to act on their urges, be it peeping, stealing, or gambling.
Punishment vs Rehabilitation
It is reasonable to believe exhibitionism is susceptible to interventions that are effective with other paraphilias. Exhibitionism can also be grouped with other disorders of hypersexuality and be treated similarly, rather than being viewed as a sexual perversion. Exhibitionists are a heterogeneous group, and often have more than one paraphilia (some could be involved in physical sexual offences), it can be difficult to decide on their disposition in Court. Taking a detailed psychosexual and forensic history would better inform if they are sick or bad. It is only humane to equally consider and balance the danger they may pose to the society, and their need to receive appropriate offence-specific treatment. Flashers do not often choose therapy, therapy is chosen for them. The Judge makes the call, of course.
Going Forward
From the police statistics, it would appear that outrage of modesty cases are on the rise. It is likely that those who committed physical offences were once hands-off offenders. Flashers are often brushed aside as perverts and are locked up in prison. It is time we try to understand their illness, and offer them much-needed treatment and support. Psycho-education is important for flashers to understand the adverse impact of their behaviour on the victims. It is equally important for both the people who prosecute and defend them to understand how the illness has driven them to offend repeatedly. It is believed that exhibitionism can be successfully treated and controlled, and newspaper headlines of “recalcitrant flashers” will become history.
Bibliography:
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th Ed). Washington, DC: Author.
Chan, A.O., Lim, L.E. & Ong, S.H. (1997). A review of outrage of modesty offenders remanded in a state mental hospital. Medicine, Science, and the Law, 37(4), 349-352.
Grant J., Levine L., Kim D., Potenza M.N. (2005). Impulse control disorder in adult psychiatric inpatients. American Journal of Psychiatry, 162, 2184-2188.
Lim, L.F.C., Tan, L.L., Sung, M., Loh, M.I., Chan, K.L. & Straughan, P.T. (2000). A review of offenders remanded in a state psychiatric hospital. Singapore Medical Journal, 41(3), 114-117.
Morin, J.W. & Levenson, J.S. (2008). Exhibitionism: Assessment and treatment. In D.R. Laws & W.T. O’Donohue (Eds), Sexual deviance: Theory, assessment, and treatment (pp.76-107). New York: Guilford Press.
Murphy, W.D. & Page, I.J. (2008). Exhibitionism: Psychopathology and theory. In D.R. Laws & W.T. O’Donohue (Eds), Sexual deviance: Theory, assessment, and treatment (pp.61-75). New York: Guilford Press.
Ward, T., & Siegert, R.J. (2002). Toward a comprehensive theory of child sexual abuse: A theory knitting perspective. Psychology, Crime, and Law, 9, 315-351.
